IRDA Reg. No: 115 ICICI LOMBARD GENERAL

ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED

CLAIM FORM FOR ALL RISK INSURANCE

All the fields are mandate, Please fill the details

(The issue of this form is not to be taken as an Admission of Liability)

I .TO BE FILLED BY BANK OFFICIAL Address to dispatch Claim Documents: Cover Note / Policy No

ICICI Lombard Health Care Period of Insurance

ICICI Bank Tower, Plot No.12, Financial Date of Loss

District, Nanakram Guda, Gachibowli, Claim Number: Hyderabad, Andhra Pradesh PIN No. 500032.

I .TO BE FILLED BY CUSTOMER

1. Details of Insured

(i) Card Holder Name

(ii) Secondary Card Holder Name

(iii) Card Number

(iv) Savings Account Number

(v) Address/Contact number for correspondence

2. Nature of Transaction

3. Brief Description of Accident

4. Place & Loss Location

ICICI Lombard General Insurance Company Ltd. IRDA Reg. No: 115 Registered & Corp. Office: ICICI Lombard GIC Ltd, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayaka Temple, Prabhadevi, Mumbai - 400025 • Toll Free Number: 1800 2666

5. Date of fraudulent transaction (DOL)

6. Card Type

7. Card Statement date

8. Date and time when loss was first Discovered. (Card Blocking date) 9. Estimated value Claim (Fraud Amount)

10. Details of any other insurance policy relevant to the claim 11. Any additional information relevant to processing of claim

I/We hereby agree, affirm and declare that: (a) The statements/information given/stated by me/us in this claim form are true, correct and complete. (b) The details of all persons having an interest in the property in respect of which the claim is being made are provided as per the proposal form or by way of an Endorsement in the policy. Furthermore, save and except as provided or disclosed in this claim form, no claim made hereunder (or the same/similar claim) has been made or lodged with any other insurance company. (c) No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim has been withheld or not disclosed. (d) If I/we have given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner failed to disclose material information, the policy shall be void and that I/We shall not be entitled to all/any rights to recover thereunder in respect of any or all claims, past, present or future. (e) The receipt of this claim form/other supporting/related documents does not constitute or be deemed to constitute an agreement by the Company of the claim and the Company reserves the right to process or reject or require further/additional information in respect of the claim.

Date: Place: Signature of the Insured

Additional Details to be filled by customer/Bank

1. Customer’s relation with the Bank in terms of Years 2. Date and Time of Request for Hot Listing 3. Date and Time of Card blocking/ Hot Listing 4. No of card issued in account 5. Misuse card issue date 6. Maximum Limit of Insurance Provided 7. Daily Withdrawal Limit 8. Who blocked the card? 9. Did Customer received any SMS alert for the disputed transaction? 10. At the time of disputed transaction took place, whether card was with Customer? 11. How did the Customer realized about the misuse of card and on which date? 12. Is the card currently in possession with Customer? 13. Where did the Customer used his card last time? 14. Confirm with Customer where he was at the time of disputed transaction? 15. Is there any ATM transaction in dispute? 16. Is Police complaint lodged? If Yes, Date of police complaint 17. Date of Filing for Chargeback 18. Date of Rejection of Chargeback

Customer Profile Occupation( if salaried or self employed please mention the name of the organisation)

Designation

Date: Place: Signature of the Insured